Contact Dermatitis • Review Article COD

Contact Dermatitis

Tea tree oil: contact allergy and chemical composition

Anton C. de Groot1 and Erich Schmidt2
1 Acdegroot Publishing, 8351 HV Wapserveen, The Netherlands and 2 86720 Nördlingen, Germany

doi:10.1111/cod.12591

Summary In this article, contact allergy to, and the chemical composition of, tea tree oil (TTO) are
reviewed. This essential oil is a popular remedy for many skin diseases, and may be used
as neat oil or be present in cosmetics, topical pharmaceuticals and household products. Of
all essential oils, TTO has caused most (published) allergic reactions since the first cases
were reported in 1991. In routine testing, prevalences of positive patch test reactions
have ranged from 0.1% to 3.5%. Nearly 100 allergic patients have been described in case
reports and case series. The major constituents of commercial TTO are terpinen-4-ol,
𝛾-terpinene, 1,8-cineole, 𝛼-terpinene, 𝛼-terpineol, p-cymene, and 𝛼-pinene. Fresh TTO is
a weak to moderate sensitizer, but oxidation increases its allergenic potency. The major
sensitizers appear to be ascaridole, terpinolene, 𝛼-terpinene, 1,2,4-trihydroxymenthane,
𝛼-phellandrene, and limonene. The clinical picture of allergic contact dermatitis caused
by TTO depends on the products used. Most reactions are caused by the application
of pure oil; cosmetics are the culprits in a minority of cases. Patch testing may be
performed with 5% oxidized TTO. Co-reactivity to turpentine oil is frequent, and there
is an overrepresentation of reactions to fragrance mix I, Myroxylon pereirae, colophony,
and other essential oils.

Key words: allergic contact dermatitis; antimicrobial; aromatherapy; chemical

composition; contact allergy; essential oil; Melaleuca alternifolia; tea tree oil.

Tea tree oil (TTO) [CAS no. 68647-73-4; EG (previously
EINECS) 285-377-1] is the volatile oil obtained by dis-
tillation from the leaves and terminal branchlets of the
narrow-leaf tea tree Melaleuca alternifolia (Maiden et
Betche) Cheel.* Its INCI names are M. alternifolia leaf oil
in the EU, and M. alternifolia (tea tree) leaf oil in the United
Correspondence: Anton C. de Groot, Schipslootweg 5, 8351 HV
Wapserveen, The Netherlands. Tel: +31 521320332. E-mail: antondegroot@
planet.nl
∗ According to ISO (www.iso.org) criteria laid down in ISO 4730:2004
Essential oil of Melaleuca, terpinen-4-ol type, TTO may be obtained from
M. alternifolia (Maiden et Betche) Cheel, Melaleuca linariifolia Smith, and
Melaleuca dissitiflora F. Mueller. As commercial TTO is produced almost exclu-
sively from M. alternifolia, data from oils obtained from the other species are
not provided. Their composition, however, bears great resemblance to that
of M. alternifolia oil.
Accepted for publication 10 March 2016
States. TTO is perceived by many to be an effective remedy
for many skin conditions, and is often applied undiluted.
The first report of contact allergy to TTO was published
in 1991 (1), and many would follow. In this article, some
general information on TTO is presented, the literature
on contact allergy is reviewed, and data on the (possible)
composition of TTOs are provided. Full literature data
on contact allergy to, and the chemical composition of,
TTO and nearly 90 other essential oils (including jasmine
absolutes) can be found in the book Essential Oils: Contact
Allergy and Chemical Composition from the authors of this
article (2).
The Plant, the Oil, and Their Uses
M. alternifolia is a tall shrub or small tree up to 15 m
high with a bushy crown and papery bark. This tree is
native to Australia; it occurs naturally in the northern
coastal region of New South Wales, bordering Queens-
land. TTO, which is obtained from the leaves and terminal

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis 1
TEA TREE OIL • DE GROOT & SCHMIDT

branchlets by steam distillation, has been reported to Table 1. Chemotypes of tea tree oil [adapted from (25)]
have multiple biological activities, such as bactericidal,
Terpinen-4-ol 1,8-Cineole (eucalyptol) Terpinolene
antiviral, antifungal, anti-inflammatory, anti-tumoral,
analgesic, insecticidal and acaricidal activities (3–7). It Type 1 22–40 0–17 2–6
Type 2 <3 22–44 41–60
is seen by many as a remedy for several skin diseases,
Type 3 10–14 34–46 16–24
including acne, eczema, skin infections such as herpes Type 4 6–14 41–63 0–3
simplex and warts, wounds, burns, insect bites, dandruff Type 5 <1 72–86 <1
(8), and nail mycoses (9). It is marketed as a ‘natural’ Type 6 <1 65–80 6–14
topical antimicrobial (its antimicrobial effects are well Numbers are concentrations in % (wt/wt).
documented) and anti-inflammatory agent (10, 11). In
a monograph by the European Medicines Agency (12), Table 2. International Organization for Standardization (ISO) val-
TTO was considered to be suitable for the treatment of ues (%) for tea tree oila
small superficial wounds and insect bites, small boils
Compound CAS no. Minimum Maximum
(‘furuncles and mild acne’), itching and irritation in cases
of athlete’s foot, and minor inflammation of the oral Terpinen-4-ol 562-74-3 30.0 48.0
mucosa (12). The product is present in many different 𝛾-Terpinene 99-85-4 10.0 28.0
1,8-Cineole 470-82-6 tr 15.0
formulations, including pure oil, ointments, wart paint
𝛼-Terpinene 99-86-5 5.0 13.0
(13), acne treatments (14, 15), and household products 𝛼-Terpineol 98-55-5 1.5 8.0
such as fabric softeners, detergents, and cleansers (11, p-Cymene 99-87-6 0.5 8.0
16, 17). The oil is also used in many types of cosmetic 𝛼-Pinene 80-56-8 1.0 6.0
Sabinene 3387-41-5 tr 3.5
products (10, 11, 17), and in aromatherapy for skin
Aromadendrene 489-39-4 tr 3.0
diseases, diseases of the respiratory system (e.g. asthma, 𝛿-Cadinene 483-76-1 tr 3.0
bronchitis, sinusitis, tuberculosis, and whooping cough), Viridiflorene (ledene) 21747-46-6 tr 3.0
genitourinary diseases (candidiasis, vaginitis, cystitis, Limonene 138-86-3 0.5 1.5
and genital pruritus), fever, and infectious diseases such Globulol 489-41-8 tr 1.0
Viridiflorol 552-02-3 tr 1.0
as colds, influenza, and chickenpox (18).
TTO is sold to the public in diluted, highly concen- tr, trace.
a ISO 4730 Essential oil of melaleuca, terpinen-4-ol type ©ISO 2004;
trated, and undiluted forms. However, as products with
Geneva, Switzerland, www.iso.org.
high concentrations and, especially, aged (oxidized) oils
may induce allergic reactions, the European Cosmetics
versus preparation by hydrodistillation in the laboratory
Association COLIPA recommended in 2002 that TTO
with a Clevenger-type apparatus).
should not be used in cosmetic products in a way that
results in a concentration greater than 1% oil being
applied to the skin. Also, manufacturers were advised to Chemotypes of TTO
consider the use of antioxidants and/or specific packag- Various plant species are known to have several so-called
ing to minimize exposure to light (19). Useful reviews on ‘chemotypes’. A clear and widely accepted definition for
various aspects of TTO have been published previously (5, this well-known phenomenon is lacking. In practice,
6, 10, 12, 16, 17, 20–24). however, it means that, within a population of one plant
species with the same morphological features, groups
exist with different compositions of their secondary plant
Chemical Composition products. This is probably regulated by one or only a few
TTO is a colourless to pale yellow, clear mobile liquid genes (25). The oils produced from the various genotypes
that has a terpeny, coniferous and minty–camphoraceus are qualitatively very similar; that is, they contain the
odour. The yield of essential oil from the leaves with ter- same spectrum of chemicals, but there are major differ-
minal branches of M. alternifolia generally varies from ences in the quantities of one or several of these. Thus,
1.0% to 1.8%. The main country producing this oil is Aus- a specific chemical may be absent or present in trace
tralia; minor quantities come from China, South Africa, quantities in one chemotype, and be the dominant com-
and Vietnam. The chemical composition of TTOs may ponent in concentrations of >50% in another. Currently,
be extremely variable, depending on parameters such as six chemotypes of M. alternifolia leaf oil are commonly
biomass used (from wild or cultivated trees; only leaves or distinguished (Table 1).
leaves plus terminal branchlets), chemotype (see below), There is an obvious terpinen-4-ol chemotype (type
and mode of production (commercial steam distillation 1), an obvious terpinolene chemotype (type 2), and an

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
2 Contact Dermatitis
 TEA TREE OIL • DE GROOT & SCHMIDT

Table 3. Constituents identified in commercial tea tree oil samplesa

Constituent CAS no. Concentration range (%) Constituent CAS no. Concentration range (%)

Aromadendrene 489-39-4 0.1–2.0 𝛾-Muurolene 30021-74-0 0–0.3

Bicyclogermacrene 24703-35-3 0–1.2 Myrcene 123-35-3 0.2–4.1
𝛿-Cadinene 483-76-1 0.2–1.9 𝛼-Phellandrene 99-83-2 0.2–0.6
Calamenene 483-77-2 tr–0.2 𝛽-Phellandrene 555-10-2 tr–5.2
Camphene 79-92-5 tr–0.07 𝛼-Pinene 80-56-8 1.8–9.2
𝛽-Caryophyllene 87-44-5 0.2–1.5 𝛽-Pinene 127-91-3 0.3–1.7
1,8-Cineole 470-82-6 0.5–18.3 Piperitol 491-04-3 0.05–0.3
p-Cymene 99-87-6 0.3–19.4 Sabinene 3387-41-5 0.03–1.3
p-Cymenene 1195-32-0 0.04–3.1 cis-Sabinene hydrate 15537-55-0 tr–19.4
𝛼-Eudesmol 473-16-5 0.03–0.5 trans-Sabinene hydrate 17699-16-0 0.01–0.3
Globulol 489-41-8 0.02–0.6 Spathulenol 6750-60-3 tr–1.1
𝛼-Gurjunene 489-40-7 0.2–1.0 𝛼-Terpinene 99-86-5 2.3–11.7
cis-3-Hexen-1-ol 928-96-1 0.01–0.07 𝛾-Terpinene 99-85-4 3.1–23.0
cis-3-Hexenyl acetate 3681-71-8 0–0.02 Terpinen-4-ol 562-74-3 6.2–44.9
𝛼-Humulene 6753-98-6 tr–0.2 𝛼-Terpineol 98-55-5 1.9–4.2
Ledol 577-27-5 0.02–0.3 Terpinolene 586-62-9 0.04–45.7b
Limonene 138-86-3 0.5–3.0 𝛼-Thujene 2867-05-2 0.05–1.4
Linalool 78-70-6 0.06–0.8 Viridiflorene (ledene) 21747-46-6 0.3–2.1
p-Menth-2-en-1-ol 619-62-5 0.04–0.7 Viridiflorol 552-02-3 0.08–0.8
Methyl eugenol 93-15-2 0.01–0.4

CAS, Chemical Abstract Service (www.cas.org).

tr, trace.
a Ninety-seven tea tree essential oil samples from Australia, Vietnam, and China (n = 1), analysed between 1998 and 2013 (E. Schmidt,

unpublished data) (2).

b The very high concentration of 45.7% for terpinolene was found in one sample from China only; the median value for all oils was 3.1%.

obvious 1,8-cineole chemotype (type 5). The three
remaining chemotypes (3, 4, 6) are dominated by the
oil component 1,8-cineole, and are considered to be
1,8-cineole chemotypes that differ in the levels of either
terpinen-4-ol or terpinolene present (25). Commer-
cial TTOs are always of the terpinen-4-ol chemotype,
type 1.
International Organization for Standardization (ISO)
standard
The ISO provides standards with which the mode of
production of commercial TTOs and the oils themselves
should comply. According to ‘ISO 4730:2004, essential
oil of Melaleuca, terpinen-4-ol type’, TTO is obtained by
steam distillation of the foliage and terminal branchlets
of M. alternifolia (Maiden et Betche) Cheel, M. linariifolia
Smith, and M. dissitiflora F. Mueller. However, in practice,
commercial TTO is produced from M. alternifolia (Maiden
and Betche) Cheel (6, 25–27), which is an extremely
fast-growing tree and a constantly renewable source of
oil (28). The minimum and maximum allowed concen-
trations of the major components of commercial TTO are
shown in Table 2. The chemicals with the highest allowed
concentrations are terpinen-4-ol (48.0%), 𝛾-terpinene
(28.0%), 1,8-cineole (15.0%), 𝛼-terpinene (13.0%),
𝛼-terpineol (8.0%), and p-cymene (8.0%).
Chemical composition of commercial TTOs (own data)
One of us (E.S.) analysed 97 tea tree essential oil
samples from Australia, Vietnam and China (n = 1)
between 1998 and 2013 by gas chromatography/mass
spectrometry (GC/MS) (2). The results are shown
in Table 3. The 10 chemicals that had the highest
maximum concentrations (concentration range pro-
vided) were terpinolene (0.04–45.7%), terpinen-4-ol
(6.2–44.9%), 𝛾-terpinene (3.1–23.0%), p-cymene
(0.3–19.4%), cis-sabinene hydrate (trace–19.4%),
1,8-cineole (0.5–18.3%), 𝛼-terpinene (2.3–11.7%),
𝛼-pinene (1.8–9.2%), 𝛽-phellandrene (trace–5.2%), and
𝛼-terpineol (1.9–4.2%). The very high concentration
of 45.7% for terpinolene was found in one sample from
China only; the median terpinolene value for all oils was
3.1%. These data clearly show that not all essential oils
can be expected to comply with ISO criteria. The num-
ber of identified ingredients is relatively small, as trace
constituents (<0.02%), which are not important to the
producers and buyers of essential oils, were not quantified
and not mentioned in the oils’ profiles.
Chemical composition of TTOs from various sources
(literature data)
We reviewed the literature on the chemical composition
of TTOs up to 11 September 2014 (2), and found nearly

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis 3
TEA TREE OIL • DE GROOT & SCHMIDT

Table 4. Constituents identified in tea tree oils in the literature in concentrations of 1% or higher (2)

Highest Highest
Constituent CAS no. concentration (%) Constituent CAS no. concentration (%)

𝛿-Amorphene 189165-79-5 2.0 Oleic acid 112-80-1 1.7

Aromadendrene 489-39-4 2.0 Palustrol 5986-49-2 2.2
Bicyclogermacrene 24703-35-3 6.2 𝛼-Phellandrene 99-83-2 12.2
𝛿-Cadinene 483-76-1 2.4 𝛽-Phellandrene 555-10-2 1.9
𝛽-Caryophyllene 87-44-5 3.1 2-Phenethyl alcohol 60-12-8 15.3
1,8-Cineole 470-82-6 64.1 𝛼-Pinene 80-56-8 3.4
o-Cymene 527-84-4 4.3 𝛽-Pinene 127-91-3 1.8
p-Cymene 99-87-6 35.3 Sabinene 3387-41-5 1.6
𝛽-Fenchyl alcohol 22627-95-8 3.3 cis-Sabinene hydrate 15537-55-0 2.3
Geranial 141-27-5 2.4 Spathulenol 6750-60-3 1.3
Globulol 489-41-8 3.1 𝛼-Terpinene 99-86-5 12.9
𝛼-Guaiene 3691-12-1 1.9 𝛾-Terpinene 99-85-4 23.2
cis-𝛽-Guaiene 372162-07-7 1.4 Terpinen-4-ol 562-74-3 53.7
Hexanediol – 4.9 𝛼-Terpineol 98-55-5 11.8
Ledene oxide 882187-44-2 1.2 Terpinolene 586-62-9 45.6
Limonene 138-86-3 7.9 𝛼-Terpinyl acetate 80-26-2 6.0
Linalool 78-70-6 3.2 𝛼-Thujene 2867-05-2 1.7
Longifolene (junipene) 475-20-7 1.3 1,2,4-Trihydroxymenthane 66767-24-6 4.6
2-Methyl-5-decanone 54410-89-8 3.3 Viridiflorene (ledene) 21747-46-6 6.1
Myrcene 123-35-3 2.5 Viridiflorol 552-02-3 1.4
Neodihydrocarveol 18675-33-7 6.3

50 relevant articles presenting analyses of TTO sam-
ples, and three articles reviewing additional analytical
investigations (29–31). Analyses were nearly always
performed with GC/MS. The majority of analysed TTOs
were commercial samples [e.g. (28, 32–35)], and some
were laboratory-prepared, usually with a Clevenger-type
apparatus [e.g. (4, 36)]. The number of analysed oils
ranged from one (in over half of the publications) to
‘hundreds’ (33). Most samples were (probably) fresh,
but some investigators have analysed aged (oxidized)
oils (33, 37, 38).
In the TTOs analysed in these studies, over 220 chem-
icals have been identified. Approximately 55% of these
were found in a single reviewed publication only. The
compounds that have been found in any study in a con-
centration of 1% or higher are shown in Table 4. The
chemicals that were identified in most samples include
(highest concentrations in any study given) 1,8-cineole
(64.1%), terpinen-4-ol (53.7%), terpinolene (45.6%),
p-cymene (35.3%), 𝛾-terpinene (23.2%), 𝛼-terpinene
(12.9%), and 𝛼-terpineol (11.8%). Well-known ingredi-
ents of TTOs that were present in high concentrations
(>7%) in one or two studies only were 𝛼-phellandrene
(12.2%) and limonene (7.9%). A rare constituent of
TTO found in a high concentration (>7%) in a single
study is 2-phenethyl alcohol (15.3%). Full literature data
are presented in reference 2. It should be realized that
some studies were poorly designed or performed, and
that incorrect identifications, especially with trace con-
stituents and certainly in older studies (when analytical
methods were far from perfect), are most likely not rare.
Effect of ageing on the composition of TTOs
The composition of TTO changes, particularly in the
presence of atmospheric oxygen, but also when the oil
is exposed to light, humidity, and higher temperatures.
Under these conditions, the antioxidants 𝛼-terpinene,
𝛾-terpinene and terpinolene are oxidized to p-cymene.
Consequently, the levels of 𝛼-terpinene, 𝛾-terpinene
and terpinolene decrease, whereas the level of p-cymene
increases up to 10-fold (33, 39). Hence, the concentration
of p-cymene is a good measure of the oxidative degrada-
tion of TTO (38). Oxidation processes also lead to the
formation of peroxides, endoperoxides and epoxides such
as ascaridole (40). With increasing age, the oil develops
a green–brownish colour, the viscosity changes, and the
smell becomes turpentine-like. Finally, long thin needles
composed of 1,2,4-trihydroxymenthane crystallize (33,
39, 41).
Contact Allergy/Allergic Contact Dermatitis
Contact allergy to and allergic contact dermatitis caused
by TTO have been reported frequently. In fact, of all essen-
tial oils, TTO has caused most (published) allergic reac-
tions since the first cases were reported in 1991 from

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4 Contact Dermatitis

Australia, where TTO is produced (1). There are many
reports of routine testing; TTO 5% has been part of the
screening series of the North American Contact Dermati-
tis Group (NACDG) since 2003. In groups of consecutive
patients suspected of having contact dermatitis, preva-
lence rates of up to 3.5% positive patch test reactions
have been observed. Undiluted TTO, products with high
concentrations and formulations containing 5% TTO can
also, possibly depending on the vehicle, induce irritation
of the skin/irritant contact dermatitis (10). In this section,
data on routine testing, data on patch testing with TTO
in groups of selected patients, published case reports, the
clinical picture of allergic contact dermatitis caused by
TTO, the allergens and patch test procedures are reviewed.
Testing in groups of patients
Routine testing
We found 18 investigations in which consecutive patients
suspected of having contact dermatitis were tested with
TTO, performed or published between 1997 and 2013. In
the more recent ones, the usual test concentration was
5% in petrolatum, but, in earlier studies, higher concen-
trations (up to 100%) were used, i.e., concentrations that
are now known to have a high risk of inducing irritant
reactions. Most recent investigations were performed by
the NACDG. The results of routine testing are shown in
Table 5.
Rates of positive reactions have ranged from 0.1% to
3.5%. The highest rates were observed in the Australian
studies: 1.8% (51), 2.5% (45, 57), and 3.5% (45). In the
NACDG studies (United States and Canada), frequencies
ranged from 0.9% to 1.4% (mean 1.1%; median 1.0%)
(43, 44, 46, 48, 50). Only two non-Australian studies had
scores higher than 2%, one from the United States (47)
and the other from the United Kingdom (54). In the US
investigation, 2.1% of routinely tested patients reacted to
TTO 5%, but many reactions consisted of macular ery-
thema or were weak, and these were counted as posi-
tive (47). In the study performed in the United Kingdom,
13 of 550 patients (2.4%) reacted to pure, oxidized TTO,
which bears a great risk of false-positive reactions. Indeed,
the authors reported a staggering 38% irritant patch test
reactions to the test substance (54).
Relevance
In an Australian study, the patch test reactions to TTO of
17 of 41 (41%) patients were considered to be relevant
(51). Only 4 of these 17 patients (24%) had used cos-
metic products containing TTO (soap, hand cream, face
cream, deodorant, and hand lotion; one product each).
Two-thirds of the 41 positively reacting patients recalled
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis
TEA TREE OIL • DE GROOT & SCHMIDT
prior use of TTO, and 20% specified application of neat
(100%) TTO (51). In a study of the German Contact
Dermatitis Research Group (Germany and Austria), the
positive patch test reactions of 20 patients of 36 (56%)
were considered to be relevant (56). These patients had
used TTO-containing topical products in the (recent) past,
leading to blistering and oozing eruptions at the site of
application. All had shown ++ or +++ patch test reac-
tions. The other 16, in which relevance was uncertain or
absent, had all had a + patch test reaction to TTO only.
The causative topical products were not specified (56).
In the NACDG studies, the sum of ‘definite’ and ‘proba-
ble’ relevance ranged from 20% to 56%; in these studies,
no causative products were mentioned (43, 44, 46, 48). In
one NACDG study, no relevance data were provided (59).
Both cosmetics (including self-made products) con-
taining TTO and pure oil were causative products in
several other studies (53, 54, 58). Occupational allergic
contact dermatitis was also reported (54).
Testing in groups of selected patients
In five studies performed between 1996 and 2014, TTO
was patch tested in groups of selected patients. Selec-
tion criteria included suspicion of cosmetic dermatitis
(60), patient-reported cutaneous reactions to products
(notably cosmetics) containing botanical ingredients
(61), and previous reactivity to ascardidole, a known
allergen in TTO (42). The results are shown in Table 6.
The prevalence of reactions to TTO ranged from 1.6%
(61) to 41% (60). In the latter study, an early investiga-
tion from the United Kingdom, 7 of 17 patients (41%) sus-
pected of having cosmetic dermatitis had a positive patch
test reaction to TTO. This unrealistically high percentage
can probably be explained by the fact that the patients
were tested with pure TTO, which is known to cause many
irritant patch test reactions (54). Nevertheless, of these
7 patients, 5 specifically recalled the use of products con-
taining TTO, and a further patient may have been exposed
to the oil via aromatherapy (60).
Case reports
Many case reports and case series on allergic contact
dermatitis caused by TTO have been reported; details are
shown in Table 7.
At least 90 allergic patients have been described. Of the
cases in which the products responsible for the allergic
reactions were specified, approximately two-thirds were
related to pure TTO applied for therapeutic purposes for
a variety of skin conditions, including acne, eczema, sun-
burn, wounds (of any cause), warts, herpes, and fun-
gal infections. There were also some cases caused by
5
TEA TREE OIL • DE GROOT & SCHMIDT

Table 5. Results obtained by testing groups of consecutive patients, suspected of having contact dermatitis, with tea tree oil

Number of patients
Test concentration
Years and country and vehicle Tested Positive (%) Relevance and comments References

2011–2013, The 5% pet. 221 2 (0.9) Not relevant. Both patients also reacted to (42)
Netherlands ascaridole, an important allergenic ingredient
of tea tree oil
2011–2012, USA and 5% pet., oxidized 4231 36 (0.9) Definite + probable relevance: 56% (43)
Canada (NACDG)
2009–2010, USA and 5% pet., oxidized 4299 43 (1.0) Definite + probable relevance: 50% (44)
Canada (NACDG)
2001–2010, Australia 10% pet. 5087 129 (2.5) Relevance: 33% (45)
<2010, Australia 5% pet. 794 28 (3.5) Relevance: 43% Not absolutely certain that there (45)
was no selection
2007–2008, USA and 5% pet. 5078 71 (1.4) Definite + probable relevance: 37% (46)
Canada (NACDG)
2000–2007, USA 5% pet. 869 18 (2.1) Relevance: 100% weak study: (i) high rate of (47)
macular erythema and weak reactions;
(ii) relevance figures include ‘questionable’ and
‘past’ relevance
2005–2006, USA and 5% pet. 4435 62 (1.4) Definite + probable relevance: 36% (48)
Canada (NACDG)
<2006 USA and 5% pet. 1603 5 (0.3) Definite + probable relevance: 20% (49)
Canada
2003–2004, USA and 5% pet. 5137 45 (0.9) Relevance not stated (50)
Canada (NACDG)
2000–2004, Australia 10% and 5% pet. 2320 41 (1.8) Relevance: 17/41 (41%); only 4 patients had used (51)
cosmetic products containing tea tree oil (soap,
hand cream, face cream, deodorant, and hand
lotion; one product each); 66% of the 41 patients
recalled prior use of tea tree oil, and 20%
specified application of neat (100%) tea tree oil
<2004, USA 5% pet. 1603 5 (0.3) No details known (16)
2002–2003, 10% pet. 377 1 (0.3) Probably relevant (52)
Denmark
1999–2003, 5% DEP, oxidized 2284 21 (0.9) Relevance: percentage not specified; some patients (53)
Germany had used (self-made) cosmetics containing tea
tree oil, and others had used the neat oil for
eczema, acne, flea bites, and muscle pain, and for
evaporation in the sauna or indoors to banish
wasps
2001, UK Pure, oxidized 550 13 (2.4) Relevance: 4 relevant, 5 possibly relevant, 4 (54)
relevance unknown Two cases of occupational
allergy in a beauty therapist and a complementary
therapist; other exposures included the use of a
shaving gel and children’s shampoo; 38% irritant
patch test reactions to pure oxidized tea tree oil
<2000, Italy 5%, 1% and 0.1% 725 oil 1 (0.1) Details not known; irritant reactions to undiluted tea (55)
pet., undiluted tree oil
1999–2000, 5% DEP, oxidized 3375 36 (1.1) Current relevance 56%; range of positive patch test (56)
Germany and reactions per centre 0–2.3%; co-reactivity to oil
Austria of turpentine 39%
1999, Australia ? 477 12 (2.5) Relevance not stated. In a group of 12 patients (57)
reacting strongly to compound tincture of
benzoin, there were 5 (42%) co-reactions to tea
tree oil
1997, France 5%, 10% and 50% 1216 7 (0.6) Relevance: the patients used pure oils, creams and (58)
in arachis oil, and hair products containing tea tree oil
pure

DEP, diethyl phthalate; NACDG, North American Contact Dermatitis Group.

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
6 Contact Dermatitis
 TEA TREE OIL • DE GROOT & SCHMIDT

Table 6. Results obtained by testing groups of selected patients with tea tree oil

Number of patients
Test concentration Selection of patients (S);
Years and country and vehicle Tested Positive (%) Relevance (R); Comments (C) References

2014, The Netherlands 5% pet., oxidized 29 4 (13.8) S: patients with dermatitis who had previously been (42)
tested with ascaridole and had a (doubtful) positive or
irritant reaction to ascaridole at that time R: no
relevance found C: all 4 were also allergic to
ascaridole
2011–2012, Italy 5% pet. 122 2 (1.6) S: patients who reported adverse cutaneous reactions to (61)
products (notably cosmetics) containing botanical
ingredients in a questionnaire; they were tested with
a ‘botanical series’ R: both reactions were relevant
(not specified)
2001–2002, Sweden 5% ethanol 1075 29 (2.7) S: patients referred for routine testing who were willing (62)
to participate in a study on cosmetic use and adverse
reactions R: not stated
1998–1999, Australia Pure and 10% pet. 216 6 (2.8) S: healthy adult volunteers R: not stated C: the patients (63)
were patch tested with 10 different samples; when
‘indistinguishable’ reactions were counted, the
percentage of positive reactions rose to 4.8%; in the
subgroup of patients (63%) who had previously come
into contact with tea tree oil, the percentages were
4.6% (without ‘indistinguishable’ reactions) and
7.6% (with such reactions); probably an
overestimation
1996–1997, UK Pure 17 7 (41) S: patients suspected of having cosmetic dermatitis R: (60)
6/7 relevant

topical pharmaceutical preparations containing TTO. Six
patients (2 aromatherapists, a complementary therapist,
2 pedicurists, and a beautician) had occupational allergic
contact dermatitis caused by TTO. Thus, approximately
three-quarters of all cases are caused by the use of undi-
luted oil or products with high concentrations, usually
applied on damaged skin. Cosmetics are the cause of tea
tree allergic contact dermatitis in only 25% of all cases
[see also (51) and (53); data provided in Table 5]. Products
with low concentrations of TTO appear to induce contact
allergy or elicit allergic reactions infrequently. Indeed, of
27 cases of contact dermatitis caused by products with
TTO that were reported to the Swedish Medicinal Prod-
ucts Agency, all had a TTO concentration of 2% or higher
(91). Nevertheless, the use of shampoos containing TTO
may cause eyelid dermatitis in previously sensitized indi-
viduals (71).
Positive patch test reactions
In some articles, patients with allergic contact dermati-
tis caused by other sources co-reacted to TTO; either
this had no relevance, or the relevance was not men-
tioned or was uncertain. Because of the abundance of
other literature on TTO, these articles are not specifically
mentioned here.
Clinical picture of allergic contact dermatitis caused
by TTO
In the majority of cases of sensitization, contact
allergy/allergic contact dermatitis is caused by the appli-
cation of pure oil, usually for therapeutic purposes. This
results in localized allergic contact dermatitis at the site
of application, which may often be blistering and oozing
(56). It may either stay limited or spread, sometimes all
over the body (75). The clinical picture of reactions to TTO
in cosmetics depends on the product used. The dermatitis
is usually less severe, because of lower concentrations
of the allergen in the cosmetic products and application
to intact skin. Examples include periorbital/eyelid der-
matitis caused by soap, cream, and shampoo (65, 71),
dermatitis of the beard area caused by shaving oil (65),
dermatitis of the face caused by face cream (51), and der-
matitis of the face and hands caused by hand lotion (51).
Stomatitis has resulted from contact allergy to TTO in a
toothpaste (72).
There are several reports of allergic contact dermati-
tis caused by occupational exposure, for example in aro-
matherapists (75, 86), a beauty therapist/beautician (54,
89), complementary therapists (54, 66), and a pedicurist
(89). In the majority, the hands and/or forearms were
affected (54, 66, 86, 89).

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis 7
TEA TREE OIL • DE GROOT & SCHMIDT

Table 7. Case reports of allergic contact dermatitis caused by tea tree oil

No. of patients
Years and country allergic to tea tree oil Causative products, clinical data, and comments References

2015, Spain 5 Pure oils (64)

2013, The Netherlands 2 Soap and cream containing tea tree oil in 1 patient, shaving oil in (65)
the second patient, who had the clinical picture of folliculitis
barbae; both patients also reacted to ascaridole
2011, UK 1 Essential oil used by a ‘complementary therapist’ with contact (66)
allergy to many other oils
2000–2010, Belgium 5 Skin care products; this represented 0.5% of 959 cases of cosmetic (67)
allergy where the causal allergen was found
2000–2009, Belgium 1 Skin care product (68)
1978–2008, Belgium 2 Topical pharmaceutical preparations (69)
2007, USA 1 Pure oil used for aromatherapy (70)
2007, Australia 1 The patient was sensitized by pure oil used for acne, and later (71)
developed allergic contact dermatitis of the eyelids from using a
tea tree oil-containing shampoo
2004, Canada 1 Pure oil for aromatherapy; stomatitis from toothpaste (72)
2004, Germany 1 Pure oil on the face of a 12-year-old boy for a ‘minimal skin (73)
affection’
2003, UK 1 Pure oil on a piercing wound; contact allergy may have precipitated (74)
linear IgA disease
2002, UK 1 Pure tea tree oil; the patient was a professional aromatherapist who (75)
also reacted to many other essential oils
2000, UK 1 ‘Tea tree oil products’ used for vulvovaginitis (76)
2000, Germany 1 No details known (77)
2000, USA 1 Erythema multiforme-like contact dermatitis (id reaction) from (78)
application of pure oil to a wound
1999, Germany 8 Pure oil in 7 patients for the treatment of eczema, plantar warts, (79)
and sunburn
<1999, Germany 16 Ten patients had used pure oil for skin disorders such as eczema, (80)
warts, sunburn, and herpes (n = 9), and for ‘hygiene and
cosmetic purposes (n = 1); 1 patient developed dermatitis from
shampoo to which pure oil had been added; no data for the
other five cases
1998, Germany 1 Pure oil on psoriasis (81)
1997, UK 1 Wart paint with tea tree oil (13)
1997, France 7 Pure oils and cosmetics containing tea tree oil (58)
1997, Sweden 1 Pure oil on skin irritation (82)
1997, Germany 2 Pure oil, in 1 patient used on basal cell carcinoma; 1 also reacted to (83)
limonene and sweet orange oil
1996, USA 12 Details not known (84)
1996, The Netherlands 1 Airborne allergic contact dermatitis from inhalation of aqueous (85)
solution of tea tree oil; source of primary sensitization not
mentioned
1995, Norway 1 Hand dermatitis in an aromatherapist, primarily sensitized to (86)
lemongrass oil; positive patch test reaction to tea tree oil used at
her work. Cajeput was mentioned as synonym, so possibly it was
not the oil from Melaleuca alternifolia
1994, Norway 1 Pure oil for acne (87)
1994, Germany 7 Pure oil on skin disorders such as fungal infection, dog scratches, (88)
insect bites, and hand rashes
1994, The Netherlands 3 Pure oil; occupational contact dermatitis in two pedicurists and a (89)
beautician
1992, The Netherlands 1 Pure oil for the treatment of dermatitis; systemic contact dermatitis (90)
after oral administration; the patient co-reacted to 1,8-cineole,
an ingredient of the oil
1991, Australia 2 Undiluted oil; first 2 cases of contact allergy reported (1)

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
8 Contact Dermatitis

Allergic contact dermatitis resembling folliculi-
tis barbae (65), erythema multiforme-like contact
dermatitis (id) (78) and systemic contact dermatitis
after oral administration (90) have rarely been reported.
Airborne allergic contact dermatitis caused by inhalation
of aqueous solution of TTO has been observed (85), and
may be expected with the use of aromatherapy lamps. In
1 patient, contact allergy induced by pure oil on a pierc-
ing wound may have precipitated linear IgA disease (74).
The majority of patients with allergic contact dermatitis
caused by TTO were women.
The allergens in TTO
TTO has been extensively investigated. Its sensitizing
potential has been shown in both human and animal
experiments. Fresh TTO is a weak (80, 88) to moderate
(10, 88, 92–94) sensitizer, but oxidation increases its
sensitizing potency (80). Skin sensitization may also be
enhanced by irritancy (10). Oil stored in open bottles or
in a bottle opened several times undergoes an ageing pro-
cess. Alterations of the components because of oxidative
reactions lead to the formation of peroxides, endoperox-
ides, and epoxides, usually present in very low amounts,
formed by the oxidation of terpinen-4-ol and 𝛼-terpinene
(95). These chemicals are strong sensitizers (39, 80,
96). Knight and Hausen, in 1994, were the first to look
for the sensitizers in TTO by testing allergic patients
with a number of the oil’s ingredients (88). Of 7 allergic
patients, 6 (86%) had positive patch test reactions to
limonene, 5 (71%) to 𝛼-terpinene and to aromadendrene,
2 (29%) to terpinen-4-ol, and 1 (14%) to p-cymene and to
𝛼-phellandrene (88). Since then, German investigators in
particular have tested a considerable number of patients
allergic to TTO with one ingredient, a few ingredients or a
battery of its constituents to identify the main sensitizers.
The results are shown in Table 8, in which the number
of patients allergic to TTO, the test concentration of the
oil, and the components reacting in patch testing, with
their test concentrations, number of positive reactions,
and percentage of positive reactions, are summarized.
The results for each individual component in the group
of 11 relevant studies (including negative reactions) are
shown in Table 9.
The most frequently reacting sensitizers in TTO
appear to be ascaridole, terpinolene, 𝛼-terpinene [and
its oxidation products (96)], 1,2,4-trihydroxymenthane,
𝛼-phellandrene, and limonene (Table 9). Other chemi-
cals that may be responsible for TTO allergy, albeit less
frequently (<16%), include myrcene, aromadendrene,
D-carvone, L-carvone, terpinen-4-ol, viridiflorene, and,
rarely (<5%), sabinene, 1,8-cineole, and p-cymene. The
© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis
TEA TREE OIL • DE GROOT & SCHMIDT
TTO components 𝛼-pinene, 𝛽-pinene, 𝛾-terpinene and
𝛼-terpineol have thus far not been identified as sensitizers
in TTO (Table 9). It should be appreciated, however, that,
with the exception of 𝛼-pinene, these chemicals have
been tested in a only few patients allergic to TTO. Most
of the sensitizers have been found in low concentrations
or not at all in commercial TTOs; for some (e.g. ascari-
dole, which is formed during the oxidation of TTO, and
1,2,4-trihydroxymenthane, which is formed during the
ageing process), this can be explained by the fact that
these were fresh oil samples (Table 4).
Most positive patch test reactions to TTO are proba-
bly result from sensitization to the oil itself. However, in
some cases, they may possibly reflect prior sensitization to
an ingredient of the oil. Thus, of 14 patients with occu-
pational contact dermatitis caused by D-limonene who
were patch tested with TTO 5% pet., 5 (36%) had a pos-
itive (n = 4) or doubtful positive (n = 1) reaction to TTO,
although they denied having prior contact with it. This
may indicate that previous contact allergy to limonene
can result in a positive patch test reaction to TTO (59). In
line with this, some authors have suggested that reactions
to limonene may be the result of presensitization to fra-
grances, rather than being caused by the use of TTO (80).
Patch testing with TTO
Indication
Patch testing with TTO is indicated when the history of the
patient suggests an allergic reaction to the oil or products
containing it. In the majority of cases, this will probably be
the pure oil, as neither the history nor the clinical picture
will alert the clinician to reactions to TTO in, for example,
cosmetics, pharmaceutical products, or household prod-
ucts. Preferably, the TTO-containing product used by the
patient should be patch tested at a dilution of 5–10% TTO
in an appropriate vehicle such as pet. Concentrations up
to 25% may have little irritancy potential (92), but the use
of higher concentrations may result in extreme patch test
reactions.
Oxidized TTO 5% in pet. is available as a patch test sub-
stance from Chemotechnique (www.chemotechnique.se)
and from Allergeaze (www.allergeaze.com). The preva-
lence of positive reactions to TTO in consecutive patients
in most countries does not warrant its addition to the
baseline series. In Australia, however, inclusion seems
to be indicated, and has, indeed, recently been recom-
mended (45), as routine testing has yielded frequencies of
sensitization ranging from 1.8% to 3.5% (45, 51, 57). It is
unknown whether the inclusion of TTO in any additional
series will frequently result in unsuspected currently rel-
evant positive patch test reactions, but this is doubtful. Of
9
TEA TREE OIL • DE GROOT & SCHMIDT

Table 8. Testing with ingredients in patients with positive patch test reactions to tea tree oil

No. allergic to Positively reacting ingredients, test concentration

tea tree oil (test and vehicle, numbers positive, percentage positive
Years and country concentration/vehicle) (in parentheses), and comments References

2011–2013, The 6 (5% pet.) All reacted to ascaridole 1% and/or 2% and/or 5% in pet. (42)
Netherlands
2009–2013, Spain 4 (5% pet. and pure) All reacted to oxidized D-limonene (concentration/vehicle unknown) (97)
1999–2003, 20 (5% DEP) Terpinolene 5% DEP, n = 17 (85%); ascaridole 5% DEP, n = 15 (75%); (53)
Germany 𝛼-terpinene 5% DEP, n = 16 (80%); 1,2,4-trihydroxymenthane 5% pet.,
n = 13 (65%); 𝛼-phellandrene 5% DEP, n = 7 (35%); D-limonene 5%
DEP, n = 11 (55%); myrcene 5% DEP, n = 7 (35%); viridiflorene 5% DEP,
n = 1 (5%); D-carvone 5% DEP, n = 4 (20%); L-carvone 5% DEP, n = 4
(20%); aromadendrene 5% DEP, n = 1 (5%); sabinene 5% DEP, n = 2
(10%); terpinen-4-ol 5% DEP, n = 1 (5%)
2000, Germany 8 (20% olive oil) Terpinolene 10% aq., n = 7 (88%); ascaridole (5% aq.), n = 7 (88%); (79)
𝛼-terpinene 5% aq., n = 6 (75%); 𝛼-phellandrene 5% aq., n = 5 (63%);
1,2,4-trihydroxymenthane 5% pet., n = 2 (25%); D-carvone (5% aq.),
n = 1 (13%); terpinen-4-ol 10% aq., n = 1 (13%)
2000, Germany 15 (test All were tested with 1,2,4-dihydroxymenthane, and 11 (73%) reacted (39)
concentration/vehicle positively
not specified)
1999–2000, 10 (5% DEP) Terpinolene 10% DEP, n == 10 (100%); ascaridole 5% DEP, n = 10 (100%); (56)
Germany and 𝛼-terpinene 5% DEP, n = 10 (100%); 1,2,4-trihydroxymenthane 5% DEP,
Austria n = 9 (90%); 𝛼-phellandrene 5% DEP, n = 6 (60%); D-limonene 5% DEP,
n = 4 (40%); myrcene 5% DEP, n = 1 (10%); viridiflorene 5% DEP, n = 1
(10%)
1999, Germany 16 (test vehicle not Terpinolene 10%, n = 16 (100%); ascaridole 5%, n = 12 (75%); (80)
mentioned)a 𝛼-terpinene 5%, n = 11 (69%); 1,2,4-trihydroxymenthane 5%, n = 8
(50%); 𝛼-phellandrene 5%, n = 5 (31%); myrcene 5%, n = 2 (13%);
D-limonene 5%, n = 1 (6%); viridiflorene 5%, n = 1 (6%)
1998, Germany 1 (concentration/vehicle ?) 1 reaction to ascaridole; article not read (40)
1997, Australia 3 (varying test 𝛼-Terpinene, n = 1; 3 patients reacted to a sesquiterpenoid hydrocarbon (92, 93)
concentrations) fraction and sesquiterpenoid mixed with paraffin to obtain a
concentration as in 25% tea tree oil
1994, Germany 7 (1% solution) D-Limonene 1% ethanol, n = 6 (86%); 𝛼-terpinene 1% ethanol, n = 5 (88)
(71%); aromadendrene 1% ethanol, n = 5 (71%); terpinen-4-ol 1% and
5% ethanol, n = 2 (29%); p-cymene 1% ethanol, n = 1 (14%);
𝛼-phellandrene 1% ethanol, n = 1 (14%)
1992, The 1 (pure) 1,8-Cineole (eucalyptol) 5% pet., n = 1 (100%) (90)
Netherlands

DEP, diethyl phthalate.

a Test concentrations were probably in DEP for all allergens except 1,2,4-trihydroxymenthane, which was tested in pet. (53).

the ingredients of TTO that have caused contact allergy,
only limonene and carvone are available as commercial
patch test materials. For testing with the important sensi-
tizer ascaridole, a test concentration of 2% has been rec-
ommended (42). Higher concentrations may reveal more
cases of sensitization, but also result in some 10% doubtful
and 10% irritant reactions (42).
Co-reactivity
Oil of turpentine. There appears to be frequent co-reactivity
to oil of turpentine in patients reacting to TTO. The
German Contact Dermatitis Research Group tested 3375
consecutive patients suspected of having contact dermati-
tis in 1999 and 2000 in 11 clinics in Germany and
Austria (56). There were 36 (1.1%) positive reactions to
TTO. Fourteen of these patients (39%) co-reacted to oil of
turpentine 10% in pet., which is part of the baseline series
in these countries (56). In another German study (80),
concomitant reactions to oil of turpentine were seen in 7
of 16 (44%) patients allergic to TTO, and co-reactivity was
also observed in a case report (73).
A commercial oil of turpentine test substance used
by the members of the German Contact Dermatitis
Research Group contained 72% 𝛼-pinene, 15% 𝛽-pinene,
5% dipentene (limonene), 2% caryophyllene, 1% cam-
phene, 1% myrcene, 1% longifolene, 0.1% carenes, and
3% unidentified components, with a peroxide degree of
30% (98).

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
10 Contact Dermatitis
 TEA TREE OIL • DE GROOT & SCHMIDT

Table 9. Summary of patch testing with ingredients of tea tree oil

Number of patients per study Total number of patients in 11 studies

Tea tree oil component Tested Positive % Positive References Tested Positive % Positive Range positive (%)

Ascaridole 20 15 75 (53) 61 51 84 75–100

10 10 100 (56)
16 12 75 (80)
8 7 88 (79)
6 6 100 (42)
1 1 100 (40)
Terpinolene 20 17 85 (53) 64 50 78 0–100
16 16 100 (80)
10 10 100 (56)
8 7 88 (79)
7 0 0 (88)
3 0 0 (93)
𝛼-Terpinene 20 16 80 (53) 64 49 77 33–100
16 11 69 (80)
10 10 100 (56)
8 6 75 (79)
7 5 71 (88)
3 1 33 (93)
1,2,4-Trihydroxymenthane 20 13 65 (53) 69 43 62 25–90
16 8 50 (80)
15 11 73% (39)
10 9 90 (56)
8 2 25 (79)
𝛼-Phellandrene 20 7 35 (53) 54 23 43 31–63
16 5 31 (80)
10 6 60 (56)
8 5 63 (79)
Limonene 3 0 0 (93) 73 29 40 0–100
D-Limonene 20 11 55 (53)
16 1 6 (80)
10 4 40 (56)
8 0 0 (79)
7 6 86 (88)
5 3 60 (64)
D-Limonene (oxidized) 4 4 100 (97)
Myrcene 20 7 35 (53) 61 10 16 0–35
16 2 13 (80)
10 1 10 (56)
8 0 0 (79)
7 0 0 (88)
Aromadendrene 20 1 5 (53) 61 6 10 0–71
16 0 0 (80)
10 0 0 (56)
8 0 0 (79)
7 5 71 (88)
D-Carvone 20 4 20 (53) 61 5 8 0–20
16 0 0 (80)
10 0 0 (56)
8 1 13 (79)
7 0 0 (88)
L-Carvone 20 4 20 (53) 54 4 7 0–20
16 0 0 (80)
10 0 0 (56)
8 0 0 (79)

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Contact Dermatitis 11
TEA TREE OIL • DE GROOT & SCHMIDT

Table 9. Continued

Number of patients per study Total number of patients in 11 studies

Tea tree oil component Tested Positive % Positive References Tested Positive % Positive Range positive (%)

Terpinen-4-ol 20 1 5 (53) 64 4 6 0–29

16 0 0 (80)
10 0 0 (56)
8 1 13 (79)
7 2 29 (88)
3 0 0 (93)
Viridiflorene 20 1 5 (53) 54 3 6 0–10
16 1 6 (80)
10 1 10 (56)
8 0 0 (79)
Sabinene 20 2 10 (53) 38 2 5 0–10
10 0 0 (56)
8 0 0 (79)
1,8-Cineole (eucalyptol) 20 0 0 (53) 62 1 2 0–100
16 0 0 (80)
10 0 0 (56)
8 0 0 (79)
7 0 0 (88)
1 1 100 (90)
p-Cymene 20 0 0 (53) 64 1 2 0–14
16 0 0 (80)
10 0 0 (56)
8 0 0 (79)
7 1 14 (88)
3 0 0 (93)
𝛼-Pinene 20 0 0 (53) 64 0 0 0
16 0 0 (80)
10 0 0 (56)
8 0 0 (79)
7 0 0 (88)
3 0 0 (93)
𝛽-Pinene 3 0 0 (93) 3 0 0 0
𝛾-Terpinene 3 0 0 (93) 3 0 0 0
𝛼-Terpineol 7 0 0 (88) 10 0 0 0
3 0 0 (93)

Ingredients of these preparations that have been found
as sensitizers in TTO include limonene and myrcene
(Table 9). In the second half of the 1990s, a sudden
increase in the prevalence of positive patch test reactions
to oil of turpentine was noticed (98). It has been sug-
gested that this can partly be explained by primary TTO
sensitization (56), oil of turpentine reacting to common
allergenic ingredients, or cross-reacting substances.
Indeed, of 16 turpentine-positive patients who denied
contact with turpentine, and who were tested with their
own TTO preparations, 10 (63%) showed positive patch
test reactions to TTO (98).
Other co-reacting substances. In patients allergic to TTO,
co-reactions to fragrance mix I (58, 66, 75, 80, 85,
86, 89), Myroxylon pereirae (balsam of Peru) (66, 75,
78, 80, 89), colophonium (rosin) (58, 74, 75, 78–80,
85, 87, 89) and one or more essential oils (56, 66,
75, 76, 80, 85, 86, 89) have been observed regularly.
Although there appears to be an overrepresentation, the
data are insufficient to show whether the frequencies
of co-reactivity are significantly increased, and, if so,
whether they are attributable to concomitant sensitiza-
tion, cross-reactivity, or pseudo-cross-reactivity (common
allergenic ingredients). However, the association between
TTO and oil of turpentine reactions seems to be clear
(∼40% co-reactivity to oil of turpentine (56, 80). In turn,
turpentine-sensitive patients react significantly more
frequently to the fragrance mix (46% of the patients ver-
sus 9.4% of turpentine-negative patients), to Myroxylon

© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
12 Contact Dermatitis

pereirae (29% versus 7% of turpentine-negative patients),
and to colophony (23% versus 3% of turpentine-negative
patients) (98).
In a group of 12 patients reacting to compound tinc-
ture of benzoin [benzoin 10%, aloe 2%, styrax 8%, Myrox-
ylon balsamum (balsam of Tolu) 4% in 95% ethanol], 5
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Contact Dermatitis
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